Help Me Understand My APAP

Help!

I don't understand what is going on here. Is AutoSet working properly?

The pressure does not seem to respond to my apnea clusters, even though they are sprinkled with hypopneas as well. I know that AutoSet ignores apneas at pressures of 10 or greater in order to avoid inducing centrals, but this is perplexing. Notice the pressure rise around 8 am, when there are no events at all. Is it responding to sub-hypopnea flow limitations?

The original prescription settings were 5 - 20 cm H20. I didn't have a titration study, but hoped to narrow the range once I had data.

I upped the min from 5 to 10.6 in stages but saw no real improvement (via the LCD, I didn't have software then.) After a visit to the nurse practitioner (who only looked at summary data,) I backed the pressure down to a min of 8 (the NP wanted it back to 5, but I negotiated.) Last night (shown above) I raised the min to 10. Max has always stayed at 20.

Would I be better off with a Respironics Auto, which has a limited response to apneas at any pressure? (Velbor, since I notice that you have both brands of APAP, do you have an opinion on this?)

Should I raise my min pressure to 12 or 13? It has to get better than this.

The NP wanted me to add a chinstrap but I don't have one yet. I have been using DentuGrip strips just in case. I don't have dry mouth, and keep my tongue up and back when I sleep, so I don't think that mouth breathing is a major issue.

And one more question: What does the height of the apnea bars mean? Seconds?

Any suggestions would be most gratefully appreciated.

The only easy and sure answer I can give you is that the height of the red bars, and the numbers at the top of the bars, do indeed represent apnea duration in seconds.

Beyond that, I am at a loss. I am puzzled to see that the AHI tracing and the events graphics seem to suddenly cease after 8 hours. Even more puzzling would be the explanation that you suddenly and inexplicably had NO events in the 1.5 hours after that.

With long and frequent apneas, this is certainly not a desirable picture. (Is it similar to previous nights for which you have data? Or an isolated anomaly of some kind? From the beginning - you say that there has been no improvement - has your AHI been this high?)

There's no way to know ahead of time (and little enough way to validly compare even in retrospect) whether one machine would be better for you than another.

I wouldn't be worrying about leak at this point; that aspect isn't bad at all.

Knowing nothing else, what I think I would do myself at this point (I cannot recommend that you do anything other than what your clinician has prescribed) would be to switch to constant-pressure CPAP mode, and see what happens. I would be torn between setting a lower pressure (perhaps to 9, out of concern that some of the apneas might be central in origin) versus a higher pressure (perhaps to 12, since you are currently at a median of 11). Much of the choice would depend, for me, on what had gone on during prior nights. [EDIT: Be aware that any such change will be apparrent to your clinician on the summary data.]

Blessings, Velbor

It's one of my worse nights, but not that far from typical, either.

Below is data from a better (but far from good) night.

My initial sleep study found no central apneas. The NP I saw mentioned "CPAP Emergent Central Apneas", but thought it was way too soon to consider that. I think that this is siimilar to the Complex Sleep Apnea Syndrome (CompSAS) mentioned in this fourm.

The apnea clusters may be due to my rolling onto my back. I go to sleep on my side, but....

I thought that the APAP would deal with this much better.

jdm,

I like the idea of going to straight CPAP since you are having apnea events above and below the "magic" 10 cm H2O. If it were me, I'd try 11 (+ some fraction) cm H2O with no EPR or even APAP set to 11 - whatever and see what happens, but that's me.

Good luck

jdm2857 wrote: . . . I didn't have a titration study . . .

After seeing those charts, I might want one.

jdm2857 wrote: . . . The NP I saw mentioned "CPAP Emergent Central Apneas", . . .

It might be nice to wear belts and find out.

If it was me...

I would switch the AutoSet to CPAP mode with a pressure of 11 for the first night and from that point forward it would be a process of monitor, adjust (slowly) and more monitoring.

With this, as I did, you will discover a pressure at which your events are controlled.

jdm2857 wrote:Help!

I don't understand what is going on here. Is AutoSet working properly?

It seems to working as it was planned to work

The pressure does not seem to respond to my apnea clusters,

They appear above 10 cms, so the machine won't raise its pressuer/

even though they are sprinkled with hypopneas as well.

The Autoset never responds to hypopneas - that too is intentional

I know that AutoSet ignores apneas at pressures of 10 or greater in order to avoid inducing centrals, but this is perplexing. Notice the pressure rise around 8 am, when there are no events at all. Is it responding to sub-hypopnea flow limitations?

The Autoset's "three lines of defense" are apneas, snores and flow limitations. ResScan shows you only the first of those three. It's a reasonable assumption that the pressure is being raised in response to flow limitations.

The original prescription settings were 5 - 20 cm H20. I didn't have a titration study, but hoped to narrow the range once I had data.

It has to get better than this.

Yes, it does.

What does the height of the apnea bars mean? Seconds?
Yes.

In the two charts presented, your % of time in apnea is much better when the minimum pressure is 8.

Have you been giving you body enough time to acclimate to the various pressure settings?



O.

I agree with ozij......again.

However, reading through the posts and looking at your reports, I haven't seen this question raised......
In what position(s) do you sleep?
It appears to me that those clusters of events could be occurring while you are on your back. If that's possibly the case, you might try to make sure you sleep on your side(s).


Den

I spent a week with the min pressure set to 8, that was the fourth, and best night at that pressure.

It is very possible that I spend time sleeping on my back. I start out on my right side, but know that I move around. If I awaken, I position myself on one side or the other. I don't usually wear PJs, so the tennis ball trick won't work. I know that people use backpacks but that sounds pretty bad. Are there any other tricks?

I think I may try pushing the minimum pressure up to 12, to see if that makes things better or worse. If it's better, it will indicate obstruction; if worse, central.

Also, is it possible that those apneas are central when they are clustered will all of those hypopneas? Hypopneas cannot be central, of course.

jdm2857 wrote:I spent a week with the min pressure set to 8, that was the fourth, and best night at that pressure.

It is very possible that I spend time sleeping on my back. I start out on my right side, but know that I move around. If I awaken, I position myself on one side or the other. I don't usually wear PJs, so the tennis ball trick won't work. I know that people use backpacks but that sounds pretty bad. Are there any other tricks?

I think I may try pushing the minimum pressure up to 12, to see if that makes things better or worse. If it's better, it will indicate obstruction; if worse, central.

Also, is it possible that those apneas are central when they are clustered will all of those hypopneas? Hypopneas cannot be central, of course.

Yep. I've read about "wedge" pillows to put behind your back while sleeping.

It's "possible". However, without ruling out some other possibilities or having a sleep study, you won't know for sure.

Wrong. There IS such a thing as "Central Hypopneas". Do a Google search.


Den

Central hypopneas? I haven't come across that before. I thought that since a hypopnea is a flow-limited breath, that the brain had to be triggering that breath.

I did have an initial sleep study without titration. It revealed an AHI of 43.6. AHI was 67.5 supine, 37.6 lateral recumbent, and 30.4 prone.
In total there were 132 obstructive apneas, 0 central apneas, and 96 hypopneas in 314.9 minutes.

jdm2857 wrote:Central hypopneas? I haven't come across that before. I thought that since a hypopnea is a flow-limited breath, that the brain had to be triggering that breath.

I did have an initial sleep study without titration. It revealed an AHI of 43.6. AHI was 67.5 supine, 37.6 lateral recumbent, and 30.4 prone.
In total there were 132 obstructive apneas, 0 central apneas, and 96 hypopneas in 314.9 minutes.

I doubt that you have a problem with Central "anything".
My suggestion would be to set that thing in CPAP mode at 10 or 11 and start working up if necessary. And, try hard to stay off your back.


Den

About trying to stay off your back. I have been trying this also. I don't have time for long narrative but I have documented REM staged sleep severe OSA (Ozij and Den are familiar with my trials). But...... I also wind up on my back often..... I don't want to stop the REM sleep but I did want to try to stay off my back to see if I could stop those annoying clusters that I get which are very similar to yours. My sleep study documents the REM stage being worse but they had me on my back the whole time. Maybe if I wasn't on my back REM wouldn't be so bad? Who knows which came first? Doesn't matter but I was more than willing to try anything in an effort to decrease the events that my machine had to try to respond to.

Forget the wedge pillow unless you sew it in place. It slides even with my little body frame and tossing and turning.
Forget large regular bed pillows for the same reason. Easily dislodged. Rolled up quilt PITA and makes bed hotter.

Some sort of workable stationary support is needed to prevent me from rolling over onto my back but not annoying enough to wake me up. Kinda defeats the whole "get better sleep" thing. Tennis balls and backpack, not an option for me. Aversion therapy, pain may work for others but I don't want to spend 4-6 weeks of miserable sleep to train myself to sleep on my side. Besides I prefer to sleep in the buff.

Last night I moved Bret's buckwheat pillow that I am trying from my neck to my lower back and pelvis. It is heavy enough that it won't slide. It is very comfortable and when I roll back on it I end up being at about a 60 degree angle with wonderful support on my back. I can sleep that way quite comfortably and move back to my side easily. I need to get a lobby started to talk Bret into offering a buckwheat body pillow. I only found 2 others on the market. Below is my last night's report. I think it speaks for itself. I was either on my side or semi side the whole night. This was much nicer than tennis balls.

Find some way to at least try being on your side the whole night. Won't know till you try.
Brenda
The neck pillow was a big help. Gotta run. Got big weekend of work planned.
I feel pretty good today. Look at those absent clusters......

As I understand it, "CPAP emergent central apneas" are ones that emerge as a result of the pressure of CPAP, so they appear only during titration and subsequent use, though they might go away. Judging strictly by the two charts given, higher pressure may have made the problem worse. The Autoset is designed to respond to the indicators (precursors) that an apnea is (or will be) obstructive, and does so at any pressure. That being said, if the apneas in your charts are obstructive, Autoset may very well NOT contain the right algorithm for you as far as an auto, and running in straight CPAP may be something to try. I still say I would still want a titration study to see if events were central or mixed. But hey, that's just me.

I upped the min pressure to 11.4 (in APAP mode) and will leave it there for several nights. I also tried to keep myself on my side with pillows. I thought I was successful but I really don't know for sure.

The LCD display numbers from last night are pretty bad:

95% pressure 13.6
Leak........... 0.42
AHI........... 24.8
AI............. 10.5
HI............. 14.3

I don't have time to download, crop, upload and post the data right now. unfortunately.